House Republican have just unveiled the long-awaited “replace” part of their promise to repeal and replace the Affordable Care Act. And, huzzah! – they’ve retained some modicum of sense and decided to keep some popular and very necessary components like guaranteed coverage for people with pre-existing conditions. But there are also a lot of less favorable components to unpack and discuss, so let’s start by focusing on one basic component of the ACA that’s been a point of tension for many of those opposed to it: mandated healthcare coverage.

Nobody wants to pay a penalty for not having health insurance. I get that. It’s not exactly unprecedented – I mean, in most states, if you’re caught driving without auto insurance, you can face penalties of several hundred dollars and some jail time, and may be ineligible to make injury claims against a driver who causes a damaging accident, even if the other driver is 100% at fault (so if you’re driving uninsured, let’s hope you have health insurance!). But if you felt you could afford to pay for health insurance, you probably would; and paying a penalty for not having that insurance seems to hit you when you’re already down.

The disconnect between the motivations behind mandated coverage and the mindset that paying penalties is unfair lies in the scope: mandated coverage is intended for the good of the group, and objections to it operate at the level of the individual.  

Since I’m already diving into controversy here, we might analogize it to vaccines: some may view mandated vaccination as an infringement on individual rights, but the effectiveness of vaccines depends on herd immunity. There are any number of individual liberties that end where they begin to pose a threat to the life and liberties of others (the choice to drive while intoxicated, for example), and the choice to leave your children unvaccinated poses life-threatening danger to those too young or ill to be able to receive vaccines. If a single person chooses not to vaccinate, they have decent odds of being covered by the immunity of the herd; odds are pretty high, in fact, that that person will not get sick. That’s how newborns, people with compromised immune systems and others who are ineligible for routine vaccinations remain relatively safe from vaccine-preventable illnesses. However, if lots of people choose not to vaccinate, we begin to see the resurgence of preventable diseases that had become almost nonexistent in the United States. If lots of people choose not to vaccinate, herd immunity weakens; those who need it most are no longer safe; people die.

Similarly, functional health insurance depends on herd coverage. Many of us pay for healthcare coverage; many of us don’t use it beyond a well visit here and there, and maybe treatment for the occasional respiratory bug that won’t go away on its own. And, others of us could never pay enough in premiums to make up for the exorbitant amounts our insurance companies have paid out for our very expensive healthcare. If a single young, healthy person opts out of healthcare coverage, they have fairly decent odds of not having a medical catastrophe or suddenly developing a chronic illness, relatively low odds of either drowning in medical debt or dying from lack of treatment, and the group is not hurt much by the absence of that one member. But if more and more healthy people choose to opt out, well — you have to have a lot of healthy people paying for insurance in order for the insurer to be able to afford to pay the healthcare costs of those who actually need to use the insurance.

This is not Obamacare theory; this is not socialism; this is Insurance 101. If lots of people choose to opt out of healthcare coverage, you begin to approach a point where there’s not a big enough pool of healthy people paying for coverage to cover the expenses the insurer is paying out for those who need more extensive care. Herd coverage weakens; insurers begin to cover less, and pay less for the things they are covering; those who need it most are no longer able to access the care they need; people die.

The Republicans’ proposed plan would remove the mandate on coverage. This may seem like a good thing – freedom of choice! But their plan also:

• Revises the financial assistance available to help pay for healthcare coverage. The proposed tax credits will be lower, in many cases, than the current subsidies made available by the ACA. Fewer people will be able to afford coverage.
• Proposes to put caps on Medicaid expansion, to an extent that even some GOP senators are saying will be damaging to those currently covered by state Medicaid policies. Fewer people will have access to the coverage and care they need.
• Allows insurance companies to charge people a 30% penalty upon purchasing a new plan, if they have let their insurance lapse – effectively continuing a penalty against the uninsured, but one that the uninsured can only avoid if they remain uninsured.

Early analyses have concluded that the proposed bill would lead to millions of people losing coverage. And without herd coverage, healthcare suffers, and people die.

I recognize that the importance of mandated coverage can be a hard pill to swallow if you’re scraping by financially, are already unable to afford health insurance, and now you suddenly have to pay a penalty on top of not being able to afford health insurance. I can sympathize. But the alternative could quite literally be the death of you.

You can find more information on the proposed AHCA here and here – and mandated coverage is just the tip of the iceberg, so look for more from me to come.  

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